1. Heart Failure: From Failure to Success
Dr. Alison Seed
Consultant Cardiologist

2. Failures? In diagnosis In routine management In advanced management
To address the personal AND financial burden

3. Diagnosis........... Prevalence >45yrs National (expected) 2.3%
Blackpool PCT (recorded)
1.8%
(0.19-5)
10-20%>70yrs, to increase
1.Pushing the boundaries: Improving services for people with heart failure. HCC(CHAI ) 2007
2. State of healthcare: Improvements and challenges for services in England and Wales. HCC (CHAI) 2007
3. Blackpool GP HF register data: Brian Harrop, Blackpool PCT

4. Routine management

5. Implant rate / million population / year
Advanced management
Implant rate / million population / year
USA
average EU UK
target
Lancs. South Cumbria 2006
ICD
610
160
100 46 28
Bi V
PPM
275 75
140 56 58

6. Personal and financial burden...
Poor prognosis
10-50% mortality per year
Poor quality of life
Poor exercise tolerance
>30% depressive illness
Frequent hospital admission
5% of acute medical admissions
40% death /readmission in one year
Long length of stay
> 8 days
2% of in patient bed days
70% cost is hospitalisation
Dr.Seth
530 ( ) – only 5% readmissions
2% total annual NHS expenditure

7. Cost

8. Hospital admission length of stay

9. Healthcare Commission 2007
HF diagnostic services poor
Diagnosis difficult because symptoms non specific and physical signs not obvious
Early diagnosis leads to appropriate life saving and symptom reducing treatment
Limited access to heart failure specialists
Need to target advanced treatments at high
risk patients
Rates of hospitalisation remain high
Healthcare Commission. Pushing the boundaries: improving services for people with heart failure. London Healthcare Commission, 2007

10. ........... to our Patients with Heart Failure?
Are we offering
Advanced Care or
Palliative Care
to our Patients with Heart Failure?

11. Palliative Care that could be better !!
Currently (2009)….
Inequitable care
Only for the symptomatic patient seeking help
No more than Crisis management for the majority
Palliative Care that could be better !!

12. National drivers Quality Outcomes Framework
‘Advancing Quality’ (NW SHA)
National HF database
Darzi report
Equitable, efficient, patient centred care
Health improvement (outcomes and quality)
Adherence to best practice (NICE, NSF)
Financial climate
Avoid hospital admission
Manage chronic disease in primary care

13. Our aim…. ‘Best care’ whenever and wherever
patients require it
Not currently seeking attention
Not yet diagnosed
With confirmed diagnosis
New presentation
In Primary Care with symptoms
Hospital admission(s)
With severe heart failure

14. Our aim....
To demonstrate that optimal care is cost saving

15. Failures?
Diagnosis
Routine management
Advanced management

16. Definition: The first problem
European society of Cardiology: ‘typically breathlessness or fatigue, either at rest or during exercise, or ankle swelling; and objective evidence of cardiac dysfunction at rest (usually on echocardiography)’

25. 25

26. New York Heart Association NYHA > II Further investigation required
The NYHA lists.....certainly patients presenting with these symptoms....
Map lists conditions that predispose pts surely we should be asking patients who attend if they would in fact put themselves in one of these groups.
Consider looking for symptoms in at risk population 26

27. BNP
Brain-type Natriuretic Peptide (BNP) is a hormone, secreted in the ventricular myocardium during periods of increased Atrial and ventricular wall tension
It is the most powerful marker of cardiovascular morbidity and mortality including sudden death
An elevated BNP indicates that the heart or kidneys are not working well but does not tell exactly why

28. NICE Guidance 2010 28

29. Heart Failure Diagnostic Clinic One stop Within 2 weeks
With regard to confirming the diagnosis......our cardiac centre now offers a one stop
The MAP asks you to refer those with alarm features urgently to A&E 29

30. Heart Failure Diagnostic Clinic
Comprehensive specialist assessment
History/ examination
Echocardiogram
Consideration of need for further investigation
Angiogram, TOE, stress test
Management plan
Lifestyle
Pharmacological
Non pharmacological
Device therapy
Patient education / engagement
Majority discharge to primary care
‘additional investigations’
‘management plan’
Discharge – the majority will be discharged to primary care

31. HF referral poster
AQ data

32. Failures?
Diagnosis
Advanced management
Routine management

33. Failures?
Diagnosis
Advanced management
Routine management

34. Biventricular Pacemakers
Right Atrial Lead
Right Ventricular Lead

36. ECG
P wave
QRS duration

39. Biventricular Pacemakers
Right Atrial Lead
Right Ventricular Lead
Left Ventricular Lead

42. Biventricular Pacemakers

43. Biventricular Pacemakers
36% reduction in All Cause Death / CVS death /Hospitalisation
CARE – HF: Cleland et al, NEJM, 2005

44. Referral for CRT from North Lancs/ Blackpool

45. Transplant vs. medical Rx
Butler et al. J Am Coll Cardiol, 2004 45

46. Cardiopulmonary exercise testing

47. Survival following cardiac transplant
1 year: 85%
5 years: 73%
10 years: 58% 47

48. Mechanical support: Ventricular assist devices
Outflow: Ao
Inflow: LV/LA

49. Bridge to transplant
Bridge to recovery
Destination therapy
Who should receive a VAD as bridge to transplant?

50. Heart Failure Service - Blackpool
Timely and accurate diagnosis
One stop diagnostic clinic
Appropriate/safe/rapid referral pathways
Identify high risk patients
BNP
Efficient and effective clinical care
Treatment optimisation (NICE)
Non pharmacological intervention (CRT / ICD, LVAD, Tx)
Communication , Communication, Communication

52. Thank you
Any questions?